Yale study: Earlier hospice care would improve quality of end of life

Published 8:40 pm, Tuesday, September 12, 2017

NEW HAVEN >> Older, terminally ill patients could improve the quality of their last days by accessing hospice services much sooner, according to a Yale School of Medicine-led study.

The study found that, while Medicare covers hospice when a patient is given a prognosis of six months or less to live, most patients don’t turn to the services until the very end of life. The prognosis is made according to Medicare criteria for each condition.

“I think the main message is that there are opportunities to improve care at the end of life in terms of addressing bothersome symptoms … through earlier referral to hospice,” said Dr. Thomas Gill, professor of geriatric medicine and director of the Yale Program on Aging, who is the study’s first author.

The study followed 562 people, aged 70 and older, who were not disabled at the beginning of the study but who died in the next 16 years. Gill said the average age of the patients who sought hospice services was 88.

Of those studied, 244, or 43.4 percent, utilized hospice services during the last year of life, “but about half of those entered hospice less than two weeks before they died, and hospice is not as effective over a short period of time as [it] might be for a longer duration,” said Gill, who also leads the Yale Claude D. Pepper Older Americans Independence Center, where the study was conducted.

Hospice care includes symptom relief and other forms of palliative care and therapy. Most hospice services are provided to patients in their homes, according to Gill and Deborah Hoyt, president of the Connecticut Association for Healthcare at Home, based in Wallingford, which represents 26 of the 31 hospice agencies in the state.

“Hospice is designed to identify and alleviate bothersome symptoms and to provide comfort and other measures at the end of life with the goal of enhancing quality of life rather than increasing the duration of life, and we can’t tell from our study whether hospice discussions were not occurring until near the end or whether families were unwilling to have those discussions,” Gill said.

“When you’re in your 80s and you have a condition such as cancer or serious heart failure, another that’s considered terminal, those are the times in which a patient and their physician can initiate discussions of what the goals of care are at the end of life,” he said.

Patients with cancer and advanced dementia were admitted to hospice care most often, while those who were frail were least likely to benefit. However, frailty was the most common condition that ultimately led to death, followed by organ failure, advanced dementia and cancer, according to a press release. Symptoms that might suggest hospice care include fatigue, nausea, depression, anxiety and difficulty sleeping or with memory.

Gill and Hoyt both said families should discuss patients’ desires before their illnesses become debilitating. “It puts that issue on the table and then it can be revisited at a later point,” Gill said.

He said a hospice nurse can “make recommendations about other types of equipment that may be available through Medicare to optimize one’s function at home.”

Also, “if things go well and the patient stays stable and it appears that the patient no longer needs hospice, they can transfer back to the traditional Medicare benefit,” Gill said. Fifteen percent of hospice patients leave hospice care, he said. “It’s not a one-way ticket.”

Hoyt said too many people try to avoid turning to hospice. “They call it the H-word,” she said. “People don’t want to think of it.

“As providers of care for senior adults or people with terminal illness … we want to encourage them to speak with their doctors and family members about their legacy and their preferences in terms of end of life,” Hoyt said.

Rather than lying “in a hospital bed hooked up to all kinds of wires and machines … they can remain comfortable, pain-free and at home surrounded by loved ones,” she said.

Besides specialized hospice nurses, hospice care can include social workers, music therapists and volunteers “to be with the patient, make sure that all of their final wishes are met, that they’re comfortable and they feel that they’re mentally and physically prepared for their end-of-life transition,” Hoyt said.

“Connecticut ranks last in the nation in terms of people accessing hospice care” and the average length of stay in the state is six days, she said.

“A doctor needs to have a conversation and refer the patient to a hospice provider and physicians don’t always feel comfortable having that conversation with patients. They’d rather try to treat them until their last breath and we’re trying to turn that around,” she said.

Hoyt said hospice agencies served by her organization can be located by town or provided services on the association’s website, www.cthealthcareathome.org.

The study was published Sept. 12 in the Journal of the American Geriatrics Society.

Editor's note: This story was edited to correct the number of hospice agencies represented by the Connecticut Association for Healthcare at Home.